Healthcare Provider Details

I. General information

NPI: 1922914308
Provider Name (Legal Business Name): CHARLENE JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4644 RUSH RIVER TRL
FORT WORTH TX
76123-2749
US

IV. Provider business mailing address

4644 RUSH RIVER TRL
FORT WORTH TX
76123-2749
US

V. Phone/Fax

Practice location:
  • Phone: 817-566-5252
  • Fax:
Mailing address:
  • Phone: 817-566-5252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number09977640
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: